推動ERAS邁向價值導向醫療照護──北醫附醫經驗為例

Promoting ERAS Towards Value-Based Health Care: A Case Study of Taipei Medical University Hospital

聚焦病人導向及價值醫療是當今全球健康照護品質管理之重要議題。因此，臺北醫學大學附設醫院於外科住院單位全面展開「強化手術後恢復」（Enhanced Recovery After Surgery, ERAS）方案。採回溯性分析，立意取樣將參與者分為執行ERAS組與未執行ERAS組，並分兩階段進行。首先建立院級ERAS任務小組，選定手術式及ERAS臨床路徑。第二階段由任務小組確認表現成效最佳（Best-practice）之ERAS醫囑：包含術後2小時提早進食、術後24小時提早移除導尿管，及術後8小時提早下床活動，並於本院所有外科一般病房推動。結果：從2017年9月至2018年10月共收集11,486例手術病人，ERAS組（N＝8946），未執行ERAS組（N＝2540）相較，發現有執行ERAS組改善前後術後平均住院天數顯著縮減1.0天（p＝0.030），而平均術後住院天數縮減0.9天，減少幅度為23.1％，其顯著性更高（p＝0.004）。組間比較發現兩組平均術後住院天數差（Difference of post-operation day），由改善前-0.1提高到2.4天。ERAS方案的好處不僅有助於外科病人，對醫療保健提供者及醫療機構都有相當助益；是值得力推實質改善臨床醫療照護，邁向價值為基礎的醫療保健有效策略。

Focusing on patient-oriented outcome and the value-based health care are important issues of global healthcare quality management in nowadays. Therefore, the enhanced recovery after surgery (ERAS) program was implemented in hospital-wide surgical inpatient units of Taipei Medical University Hospital. Retrospective analysis and purposive sampling was conducted. Participants were divided into ERAS group and traditional group. At first, hospital-level multidisciplinary taskforce was set up, and ERAS pathways were implemented. Second phase, three best practices (early postoperative feeding, early removal of urinary catheter and early mobilization) were identified and implemented for hospital-wide surgical units. Results of this study 11,486 surgical patients were collected in total from Sep. 2017 to Oct. 2018, ERAS group N=8946, traditional group N=2540. The post-operation days between groups comparison, ERAS group had 2.4days significant shorter than tradition group also. And the pathway variation rate comparison was non-significant in the whole through process. The benefits of the ERAS program not only contribute to the surgical patients, healthcare provider but also healthcare institutions. It's an effective strategy for improving clinical health care and toward value-based health care.